Chapter 6 Diseases & Disorders of Nervous Spring 2010

System & Sense Organs

Diseases of the Nervous Learning Objectives

System & Sense Organs
† Chapter 6: Categories 320-389
„ 320–326, Inflammatory diseases of the central
nervous system
„ 330–337, Hereditary and degenerative diseases of
the central nervous system
„ 340–349, Other disorders of the central nervous
system
„ 350–359, Disorders of the peripheral nervous system
„ 360–379, Disorders of the eye and adnexa
„ 380–389, Disorders of the ear and mastoid process
† Coding Guidelines: Section I.C.6.a. Pain
338.X
1. Identify inflammatory conditions of the
central nervous system
2. Define common sense organ disorders,
such as glaucoma, cataract, otitis, etc.
3. Assign complete and accurate codes based
on the documentation provided
4. Identify hereditary and other disorders of
the nervous system, such as paralytic
conditions, epilepsy, critical illness
neuropathy, etc.
5. Differentiate between acute and chronic
pain
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Divisions of the Nervous System Divisions of the Nervous System

† Central Nervous System
†Peripheral Nervous System
„ Brain
† Protected by cranial bones and cranial meninges „ somatic nervous system (SNS)
† Cranial meninges – continuous with the spinal meninges
and have the same basic structure „ autonomic nervous system (ANS)
† CSF – nourishment and protection against chemical or † sympathetic division
physical injury for the brain and spinal cord, 4 CSF filled
cavities within the brain called ventricles † parasympathetic division
„ Spinal cord
† Protective coverings, bony vertebrae and tough
meninges
† Meninges – connective tissue coverings that encircle the
spinal cord and brain
† Epidural space – cushion of fat and connective tissue, a
space between the dura mater and the wall of the
vertebral canal
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Inflammatory Diseases: 320–326 Infectious Diseases of CNS

† Bacterial meningitis: 320.X † Dual classification often used
† Meningitis due to other organisms: 321.x „ Code for underlying condition sequenced
† Encephalitis: 323.X first, followed by a code for the
manifestation
† Intracranial and intraspinal abscess: 324.x
„ Important to check alpha & tabular
† Phlebitis and thrombophlebitis of indexes for instructions
intracranial venous sinuses: 325.x † Example – meningitis sarcoidosis
† Late effects of intracranial abscess or „ 135 + 321.4
pyogenic infection: 326 † 135 = sarcoidosis
„ Use additional code to identify condition † 321.4 = meningitis in sarcoidosis

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Hereditary and Degenerative

Organic Sleep Disorders (327) Diseases of CNS (330–337)
† Organic insomnia † Long term chronic disability
† Organic hypersomnia † Numerous italicized codes
† Organic sleep apnea „ Code first underlying condition followed
by cerebral degeneration disorder
† Circadian rhythm sleep disorder
† May also produce psychiatric disorder
† Organic parasomnia
which would require an additional
† Organic sleep related movement code
disorders

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Hereditary and Degenerative

Diseases (330–337) Parkinson’s Disease: 332.x
† Primary: 332.0
† Examples „ Chronic, progressive disorder of the CNS
„ Alzheimer’s disease † Muscle rigidity
† Akinesia – difficulty in walking, taking small shuffling
„ Parkinson’s disease steps
† Depression and dementia
„ Huntington’s chorea † Tremor that begins in the fingers
† Secondary parkinsonism: 332.1
„ Cerebellar ataxia
„ Adverse effect of medication especially
„ Spinal muscular atrophy antipsychotic drugs
† Therapeutic Adverse Effect Code (E93X.X)
„ Motor neuron disease † E849.X Place of Occurrence
† ALS: Lou Gehrig’s disease † Medications
„ Levodopa, Sinemet, Antidepressants, Anticholinergic

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Motor Neuron Disease: 335.x Autonomic Dysreflexia: 337.3

† Amyotrophic Lateral Sclerosis: Lou Gehrig’s disease
335.20
† Life-threatening condition present in
„ Progressive denervation of upper and lower motor neurons spinal cord injuries
„ 5% of cases are inherited as an autosomal dominant trait „ Abrupt onset of excessively high blood
† Signs & Symptoms
„ Prominent and early muscle atrophy, progressive muscle
pressure
weakness, impaired speech, difficulty chewing, swallowing, „ Bradycardia, Blurred vision, sweating
breathing
† Medications † Takes precedence in sequencing of
„ Thyroid-releasing hormones to improve motor function;
Anticholinergic agent
codes
† Electromyography „ Use additional code to identify the cause
„ Muscle biopsy, CSF, Motor conduction studies, MRI, CT, † Decubitus ulcer, fecal impaction, UTI
myelogram

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Pain: 338 Pain – Read Coding Guidelines for

Page 26-29: Coding Guidelines detail
1. Used in conjunction with other codes to provide a. Category 338 as Principal or First
more detail
„ Acute, chronic pain, neoplasm-related pain. listed diagnosis
† If pain is not specified as acute/chronic, do not b. Use of category 338 Codes in
use 338.x codes except for Conjunction with Site Specific Pain
„ post-thoracotomy pain,
„ postoperative pain or
Codes
„ neoplasm related pain. 2. Pain due to devices
† A code from subcategories 338.1 and 338.2 3. Postoperative Pain
should not be assigned if the underlying
(definitive) diagnosis is known, 4. Chronic Pain
„ unless the reason for the encounter is pain
control/management and not management of 5. Neoplasm related pain
the underlying condition. 6. Chronic Pain Syndrome

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Other Disorders of CNS (340–349) Epilepsy 345.XX

† Hemiplegia and hemiparesis † Recurrent brain dysfunction associated with abnormal
„ May be a single code when cause is unknown electrical discharges of the neurons in the brain
„ Usually the result of another illness or injury and
used as an additional code † 5th Digit for Status Epilepticus (intractable)
„ 5th Digit for Dominant versus nondominant „ the rapid succession of seizures so that one begins
„ Hemiplegia must be present at discharge for coding before the symptoms of the preceding one has ended
purposes with CVAs „ Intravenous Valium for seizures in progress
„ Late effects of CVA: 438.2X
† Medications
† Infantile cerebral palsy
† Quadriplegia, paraplegia, monoplegia „ Phenytoin (Dilantin), Valproic Acid, Carbemazepine
„ Usually the result of another illness or injury (Tegretol)
† Epilepsy † Diagnostic Tests
† Migraine headache „ EEG, CT & MRI Scans, Brain Scan, LP

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Epilepsy 345.XX Peripheral Nervous System: 350–359

† Code only when stated as “epilepsy” † Disorders of peripheral and cranial
„ Do not code possible epilepsy to epilepsy nerves
„ Otherwise, use 780.3X † Polyneuropathies
† Review Index † Neuralgia, neuritis, radiculitis
„ Disorder, seizure, recurrent † Acquired and congenital/hereditary
† Codes to epilepsy conditions
„ Seizure
† Several italicized codes to indicate
† Recurrent 345.9
code first underlying condition
† Repetitive 780.39
„ Code condition first, manifestation second
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Peripheral Nervous System: 350–359 Trigeminal Neuralgia

† Examples
„ Bell’s palsy
„ Brachial plexus lesions
„ Carpal tunnel syndrome
„ Peroneal muscular atrophy
„ Polyneuropathy caused by other diseases
„ Myasthenia gravis
„ Congenital muscular dystrophy
† Painful disorder of one or more
branches of the trigeminal nerve
characterized by sudden, paroxysmal
attacks of excruciating facial pain
† Medications
„ phenytoin, narcotics, carbamazepine
† Lab tests
„ CT scan, tomography

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Bell’s Palsy Carpal Tunnel Syndrome: 354.0

† Unilateral facial paralysis or weakness † Compression of the median nerve in the
flexor compartment of the wrist by the
resulting in facial distortion transverse carpal ligament
† Medications † Signs & symptoms
„ pain and burning or tingling in the fingers
„ prednisone „ inability to clench hand into a fist,\
† Lab Tests „ worse at night and in the morning
† Medications
„ electromyography „ Analgesics, corticosteroids
† Lab tests
„ Electromyography, nerve conduction velocity
test

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Critical Illness Polyneuropathy: 357.82 Critical Illness Myopathy: 359.81

† Commonly associated with
complication of sepsis and multiple
organ failure
† Can be secondary to SIRS
† Synonyms for CIP are
„ neuropathy of critical illness,
„ ICU neuropathy
„ ICU polyneuropathy
† Difficulty in weaning patients from
mechanical ventilation
† Associated with neuromuscular
blocking agents, corticosterioids, and
neuropathy
† Additional E-code for Drug
„ Poisoning
„ Therapeutic Adverse Effect

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Disorders of the Eye and Adnexa Disorders of the Eye and

(360–369) Adnexae: (360–369)
† Knowledge of eye anatomy important † Visual impairment – classified
† Common conditions according to severity
„ Numerous infections † List eye with best vision first, followed
„ Various forms of retinopathy by code for lesser eye
„ Cystoid macular degeneration
† Legal blindness in the U.S. – severe
„ Glaucoma
„ Cataract
or profound impairment of both eyes
„ Blindness and low vision
„ Keratitis and conjunctivitis

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Corneal Injury Conjunctivitis

† Corneal flash burn, photokeratitis, † Due to infection, allergy, foreign
ultraviolet keratitis: 370.24 object, or other cause
„ Due to sun exposure or ultraviolet light exposure
or welder’s eye burn † Can be due to other conditions, like
„ Assign E926.2 as additional code, E849.X Bell’s Palsy – coded to exposure
† Cornea-scleral Lacerations keratoconjunctivitis
„ Classify to open wound 871.9
„ Assign E codes for external cause of injury and
place of occurrence

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Operations on Extraocular Muscles Cataract: 366.X

† Type † Gradual development of opacity of the
crystalline lens of the eye with painless loss
1. Recession -- lengthening of vision
2. Resection -- shortening † Senile, traumatic, or toxic
† Number of muscles involved † S&S – halos around lights, poor reading
vision, altered color perception
† If procedure is done on both eyes
† No medications
„ code twice in ICD 9-CM
† Lab tests – penlight exam of lens & pupil,
slit-lamp biomicroscopy, visual acuity test,
A-scan & B-scan ultrasonography

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Disorders of the Ear and Mastoid

Glaucoma: 365.xx Process (380–389)
† An eye disorder characterized by increased † External ear
intraocular pressure (IOP) that impairs „ Infections, cholesteatoma, impacted cerumen
vision
„ Open-angle glaucoma – blurred vision, haloes, † Middle and inner ear
pain, headaches „ Infections (otitis media), obstructions,
„ Angle-closure glaucoma – rapid loss of sight, dysfunction
sudden onset of severe head and eye ache, † Mastoiditis
cloudy cornea
† Medications † Disorders of tympanic membrane
„ Epinephrine, Pilocarpine, Beta-adrenergic † Vertiginous syndrome
blockers, Hyperosmotic agents † Tinnitus
† Tests
„ Slit lamp exam, Measure IOP, Tonography
† Deafness and hearing loss

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Acute swimmer’s ear (infective

Deafness & Hearing Loss otitis external): 380.12
† Hearing Loss † Inflammation of the skin of the
1. Conductive
† defect in conductive apparatus of the ear
external ear canal
2. Sensorineural † Signs & Symptoms:
† defect in sensory mechanism of the ear or „ Fever, moderate to severe ear pain, foul-
nerves
3. Mixed conductive and sensorineural smelling ear discharge, hearing loss
† Hearing Devices † Medications
1. External hearing aids „ Neomycin, Antibiotics, Analgesics
2. Implantable bone conduction devices
3. Implantable cochlear prosthetic devices † Tests – otoscopy, C&S

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Otitis Media: 381 to 382 Other Chapters

† Inflammation of the middle ear † Traumatic Injuries:
† acute – viral or bacterial infections † Open Wounds
„ bulging, fluid in middle ear, deep, throbbing ear † 870.X: Ocular Adnexa
pain, URI, fever, hearing loss, dizziness † 871.X: Eyeball
† chronic –tympanic membrane perforation † 872.X: Ear
„ persistent drainage from ear, persistent † 906.0: Late Effect of Open Wound [to eye or
inflammation of the middle ear ear]
† serous – dysfunction of the Eustachian tube † 907.X: Late Effects of Injuries to Nervous
„ nonsuppurative fluid accumulation in middle ear System
† Medications: „ 850.x: Concussion
„ antibiotic, acetaminophen, decongestant therapy † Codes reflect how long unconscious
„ Injuries to Nerves and spinal cord
† Tests – otoscopy, pneumatoscopy
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Other Chapters Other Chapters

† Poisonings by Drugs used to Treat Nervous † Nervous System Complication of Surgical &
System Disorders Medical Care: 997.0x
† 966.X: Anticonvulsants & Anti-Parkinsonism „ Code also condition, E Code for Surgical
† 967.X: Sedatives & Hypnotics Procedure & Place of Occurrence
† 968.X: Other CNS Depressants 7 Anesthetics
† Additional code for condition
† Personal History of Disease of Nervous
† E849.X for place of occurrence System & Sense Organs: V12.4X
† Therapeutic Adverse Effects of Drugs used to † Organ or Tissue Replaced
treat nervous system disorders † V43.0: Eye Globe
„ E936.X, E937.X, E938.X † V43.1: Lens
„ Dilantin Toxicity † States Following Surgery of Eye & Adnexa:
† Code for Effect, E936.1, E849.X for place of V45.6X
occurrence
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Other Chapters Surgical Procedures

† Fitting & Adjustment of Devices: V53.X † Chapter 1: Operations on Nervous System
„ Categories 01-05
„ Spectacles, contact lens, hearing aid
† Chapter 3: Operations on Eye
† Aftercare following surgery of nervous „ Categories 08-16
system & sense organs: V58.71 & V58.72 † Chapter 4: Operations on Ear
† Special Investigations & Examinations: „ Categories: 18-20
V72.0, V72.1 † 89.X Anatomic & Physiologic
„ Eyes & vision Measurements & Manual Exams– Nervous
System & Sense Organs
„ Ears & hearing
† 95.X: Opthalmologic & Otologic Diagnosis
† Special Screening for Neurological, Eye, & & Treatment
Ear Disease: V80.X
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